PHOTO BY TOM CROKEElsa Ronningstam, Ph.D., believes patients with NPD suffered trauma and /or neglect. Ronningstam is an assistant professor at Harvard Medical School and a clinical psychologist at McLean Hospital.

It’s not unusual to seek attention on occasion. From celebrities who walk the red carpet during special Hollywood events to the three-year old who begs his mother to “Watch me, Mommy,” we all require responsiveness from others at times.

But when does attention seeking cross the line from normal to problematic?

Rhea Antonio, Psy.D., founder and owner of Back Bay Psychology & Consulting LLC and adjunct faculty member at William James College, explained that individuals who demonstrate an “inflated sense of importance, an excessive need for admiration and lack of empathy for others,” and have difficulty regulating their emotions fit the DSM diagnosis for personality disorder with narcissistic tendencies (NPD).

She noted that these characteristics would be pervasive across multiple domains, including professional and social and occur in the absence of a medical condition.

“There are likely complex causes. There might have been a mismatch in a childhood relationship, such as a lack of secure attachment or excessive pampering or criticism. So they may develop compensatory strategies in response tocare giving,” she said.

Antonio explained that clients with NPD believe they are entitled to the goal, whether it’s a job, partner or prize and are unaware of their own motivation.

“Empathy is limited to recognizing feelings in others as they relate to self. Intimacy has a superficial quality. There is little genuine interest in others’ interests,” she said.

Furthermore, Antonio has found that anger and rage often mask a sense of shame. “When these people feel exposed, their inadequacies revealed, there is a risk for aggression and more antisocial behavior. The risk for aggression is increased with cocaine use.”

NPD is “exquisitely difficult to treat,” according to Antonio. “You have to figure out how to increase awareness of the behavior without dismantling [the patient’s] defensive responses,” she said.

Cognitive behavior therapy, dialectical behavior therapy and skill building are some of the strategies she uses. “If the behavior served a need to protect against feelings of shame, how likely will they be to give up the behaviors?”

Antonio indicated that couples and family therapy as well as group therapy could be useful treatment options. Within a group, the person with NPD might find others who share the same traits.

“They can see the same traits in others but not in themselves. It could help with affect regulation and how to deal with rage and anger.”

According to William B. Nash, Ph.D., private practitioner in Essex Junction, Vermont, he has never encountered a client with “pure” NPD. Rather, the client may display both narcissistic and borderline characteristics, what he calls “crossover” traits.

He has also found that treating this type of disorder is extremely difficult, tantamount to a “Herculean task.” He said, “Classical psychotherapy doesn’t work very well with NPD. I give the person adaptive skills to practice.”

DBT may address the mindfulness aspect of the individual, said Nash. “It helps the client recognize his own thinking and accept the need for excessive attention. But it also helps the person recognize that there are times when it’s not all about him or her.”

In some cases, referral to day hospital programs might be the best option, said Nash. “They teach on an intense level and include group therapy.”

Although statistics indicate that NPD occurs predominantly in men, Nash has found that women are more likely to be diagnosed with the disorder.

“Men can get away with the behavior more easily,” he said, referring to public acceptance of egotistic athletes and celebrities. “Women are expected to be demure. They are more relationally focused and understanding.”

Elsa Ronningstam, Ph.D., associate professor at Harvard Medical School and clinical psychologist at McLean Hospital, noted that patients with NPD may have suffered some type of trauma related to self-value and experience of neglect.

“The patient may also have been spoiled as a child and didn’t learn resilience. He or she is not prepared for difficulties and has no internal resources. Being unprepared for regular life hurdles and challenges can become much more traumatic than you first understand. Attachment between the caregiver and child is important,” she said noting three different types: avoidant, dismissive and preoccupied, but attachment can also be shifting and not possible to classify.

“More recent research recognizes both self-enhancement and vulnerability in most people with NPD,” Ronningstam added. Externally, the patient can show a sturdy, arrogant self, while they internally may struggle with inborn hypersensitivity or proneness to aggressive behavior.

“There are also those who are more detached, engaging in ‘splendid isolation,’” she said.

The aim of treatment is to convert these two sides of functioning, focusing on various techniques that integrate self-esteem while addressing issues of grandiosity, according to Ronningstam.

“The task in treatment is to find a connection, a match between the technique and the patient’s ability to address and work on his/her problems. It remains a challenging task for therapists as each patient can show very individual and specific defensiveness,” said Ronningstam. “There is still no direct evidence-based therapy for NPD.”

Motivation is one of the most important aspects of therapy, according to Ronningstam. “Some patients may need a lot of psychoeducation to understand how mental functioning works, especially if they are afraid of becoming overwhelmed by their feelings and losing a sense of control. They need to learn to be less afraid of their own internal feelings.”

Ronningstam emphasized the importance of viewing NPD not only as pathological, but also as part of life’s developmental phases. Every period in life involves challenges, such as applying for college or competition in a corporate setting. “Many important qualities in narcissistic functioning can be extremely valuable,” she said.

However, in some situations, if left untreated, the client may have “perpetual work and school problems,” relationship difficulties and failures and possibly suicidal thoughts or self-harm, according to Antonio. Psychopharmacology may be needed when anxiety or depression is also part of the profile, she added. “Substance abuse-related issues may be life limiting/threatening, in conjunction with a challenge to medication compliance.”

As the healthcare system becomes more integrated, psychologists have an opportunity to become part of the medical team that provides comprehensive care for the patient with NPD, Antonio noted.